<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" "http://www.w3.org/TR/html4/loose.dtd">
<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=UTF-8">
<title>Insert title here</title>
</head>
<body>
	<form name="n1">
		<table>
			<tr>
				<td colspan="2">Реклама</td>
			</tr>
			<tr>
				<td>Филиал</td>
				<td>
					<select>
						<option>
							Киев
						</option>
						<option>
							Харьков
						</option>
						<option>
							Донецк
						</option>
					</select>
				</td>
			</tr>
			<tr>
				<td>Рекламная площадь</td>
				<td><input type="text"></td>
			</tr>
			<tr>
				<td>Дата с</td>
				<td><input type="text"></td>
			</tr>
			<tr>
				<td>Дата по</td>
				<td><input type="text"></td>
			</tr>
			<tr>
				<td>Сумма</td>
				<td><input type="text"></td>
			</tr>
			
			<tr>
				<td>Валюта</td>
				<td>
					<select>
						<option>
							USD
						</option>
						<option>
							UAH
						</option>
						<option>
							EUR
						</option>
					</select>
				</td>
			</tr>
		</table>
	</form>
</body>
</html>